GW1--03917_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GQ6l-1) For Internal Use Only:
1.Well Contractor Information:
fx4.,WATER-ZONES'
FROM TO DESCRIPTION
Well Contractor NameM
IL
9 ft 1Q! Qit'� /rryy O 6 P11
g fL ft
NC Well Contractor Certification Number J l j�q'� y 2 l0 23
15.OIITER-CASING(foc'm Dtil�cas�ed weli�':012LIlVFIL'if$"licBble
Yadkin Well Company, Inc. T Tess MATERIAL
11n7s ft. ft. in.
Company Name A �6 e .,^ idL-X -
,tea .
Lsd I ) 's16:INN]M CASING:OR TUBING"'e'ritfiermai elased=loo' '" - .
2.Well Construction Permit W. OR 2-R V_;1 FROM I TO J DIAMETER THICKNESS I MATERIAL
List all applicable well constrictionpermits(Le.UIC,County,State,Variance,etc) 1 ft. 1 ft in-
3.Well Use(check well use): ` ft. / ft ilL 4J1
Water Supply Well: A•FROM
T 0 DIAMETER SLOT SIZE THICKNESS MATFRiAL ®'
❑Agricultural ❑Municipal/Public ft. ft. in.
[]Geothermal(Heating/Cooling Supply) residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ie;GIYOTJT"
❑Irri lion ❑Wells>100,000 GPD FROM TO MATERIAL EMPI.ACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0ft 4A ft. �P .9
❑Monitoring ❑Recovery ft. �i ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation -.
19:SAND/GRA'VEIi Pi1CIC'zf n licable.,-.
❑Aquifer Storage and Recovery ❑SallnityBarrier FROM TO MATERIAL E ILAC AENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer -10:1)RIYSZIVGI:0G attac milditionslsheetsifnecessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)-i
•FROM TO DESCRIPTION color,hardness,soillrock a size,eta
Date Well Started �A ft. ft. l
4.Date Well(s)Completed: '2Q-6 Well ID# /'i/'P`o ft. gal ft o-ir OA" 1"O G
5a.Well Location: Phone 7 213 - y 'ra fL hLrJ -•/phir°
J�tf- ,*t&e—PJ WI) ft. LAOI ft' -1rd0h -Pa ( htJ�YYJ3�
Facility/Owner Name Facility ID#(if applicable) H Oa fr• W, R —<,4 i oh3 qRy
v u a ,,k ft ft
Physical Address,City,and Zip a e's ft ft
y, ke,; z> x�rorARxs.. p�
County Parcel Identification No.(PIN) (" �"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certifrcation:
36 F 24a-s- 7 N 91 , 30tt[ L W
6.Is(are)the well(s): 90ermanent or ❑Temp orary Sigma of Certified well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an eristing well: ❑Yes or MNo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `, (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(er=,p7e-3C3a 200'and 2Qa 100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: `� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter (in.)glt Off: �•9�� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
g Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: `Id 6w Ytea.aa 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the E
(Le.auger,rotary,cable,direct push,etc.)
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Well over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �O Method of test: �)�
70% hth Date Site Visited:
13b.Disinfection type: Amount: Oz Site Visited By; N a 9
Environment Quality-Division of Water Resources Revised 6-6-2018
Pl'!Cep — --- - -